Crossing the Value-Based Healthcare Rubicon isn’t just a journey, it’s a revolution in care, where the currency is quality, and the compass is compassion. This transformation is both an economic and moral imperative, and in the alchemy of healthcare, transforming economics isn’t just about numbers; it’s the catalyst for transmuting care outcomes into golden results that enrich both lives and ledgers.

This week you have access to two of the leading minds in value transformation. We are joined by Dr. Edward McEachern (Executive Vice President and Chief Medical Officer for PacificSource) and Jenni Gudapati (Value-Based Healthcare Program Director and Clinical Associate Professor at Boise State University).

In this illuminating episode, we delve into the transformative realm of value-based healthcare with a diverse range of topics. Our insightful interview explores the value movement and its profound impact on economics and care outcomes. We unravel the intricate dynamics of care management, particularly in the context of chronic diseases, while shedding light on the crucial aspects of risk adjustment, Annual Wellness Visits, and Quality Improvement. We also investigate the concept of “Gold Carding” and the role it plays in healthcare transformation. Furthermore, we delve into higher education’s pivotal role in shaping the future of healthcare value, emphasizing the essential skills that healthcare leaders of tomorrow must possess. Tune in for an enlightening discussion that navigates the evolving landscape of healthcare, economics, and leadership!

This week’s episode is brought to you by Edifecs – an EMR-agnostic, interoperable, and AI-enabled technology helps providers unify and utilize data for a more complete digital portrait of patient populations. The result: better clinical, financial, and compliance outcomes.  To learn how Edifecs’ applications can enhance prospective risk adjustment and value-based contract performance, visit edifecs.com today.

Episode Bookmarks:

01:30 Introduction Edward McEachern, M.D. and Jenni Gudapati, MBA, RN

06:50 The slow uptake of accountable care (HCP-LAN: only 20% of healthcare payments flow through Categories 3B and 4 APMs).

07:20 Provider challenges: supply chain disruptions, labor shortages, high inflation, and the end of COVID-19 relief payments.

08:20 Congressional Budget Office projects insolvency of the Medicare Trust Fund by 2026.

08:50 The economic necessity of value-based health care to reduce unnecessary spending.

09:35 “In the shadow of COVID we have crossed this Rubicon where there is a push on the current paradigms of care delivery and payment.”

10:15 Stressor #1: The retirement of the Boomer workforce will create a 14% structural deficit in accessible labor.

10:30 Stressor #2: FFS infrastructure collides with APM adoption strategies and cannot support value transformation.

11:20 Stressor #3: Shift of hospital care delivery to the outpatient and home setting. (“It is never coming back.”)

11:50 “This chronic complex system of care that takes care of people in the post-acute setting is not adequately available in most communities.”

12:20 “LAN 3B and 4 payments will only help in the context of the operational reshaping of the health delivery system.”

12:50 Value-based consumer perspective needed: 46% cannot afford out-of-pocket healthcare expenses!

13:20 Low value services that do not track to best patient outcomes.

13:50 Revenue dependency on a sick-care model of fee-for-service medicine.

14:35 “Too many health inequities exist. We need to financially incentivize providers to take care of underserved populations.”

15:20 “Healthcare is the only industry that is Yelp proof.” (the dislocation between costs and consumerism)

16:20 What if we created a well-financed and integrated SDOH health system to work alongside the sick care health system?

17:50 The power of the Annual Wellness Visit (AWV) in patient-centered care.

19:20 Clinical intuition in assessing patient risk during the AWV (going beyond the diagnosis code).

21:35 Mapping the system of care to improve patient navigation.

22:20 Healthcare costs for chronic conditions totals $1.65 trillion—equivalent to nearly eight percent of the nation’s GDP. (Projected to be $6 trillion by 2050!)

24:50 PacificSource’s collaboration with Summit Health (ex: managing burden of illness through care management and gold carding.)

27:50 Scaling telehealth, RPM, and home-based CCM through financial incentives.

28:50 Lowering readmissions and ED utilization comes at the expense of lost FFS revenue.

29:35 Prevention programs are core to a clinician’s identity in the promotion of health and wellness.

30:50 PMPM-based prospective payment in the glidepath to value.

31:50 Systems of care for patients stratified in disease-specific high segments.

32:20 Payer-provider collaboration in gold carding.

32:50 The need for real-time bidirectional patient information.

33:50 92% believe quality of care will improve with VBP. (Recognition the care coordination is a critical success factor.)

34:20 Gold Carding as a way to streamline pre-authorizations between a provider and a health plan to support value based healthcare.

35:20 “CDS Hooks” (a HL7 specification that integrates clinical decision support and enables data exchange between payers and providers).

36:50 Dr. McEachern provides additional insights on gold carding, evidence-based PA adjudication, advanced CDS, and interoperability.

43:50 Risk adjustment is so much more than a RAF score and a lever for revenue.

45:20 Jenni expounds on the importance of risk-recapture and accurate charting strategy to reflect true burden of illness in a population.

46:50 Shared decision-making and reflective care planning as a risk mitigation strategy.

49:35 A RAF increase of 0.1 in a population of 1,000 patients = $1M

50:50 Boise State University’s Value-Based Healthcare Program – nationally-recognized education for preparing future healthcare visionaries.

52:50 Master of Population and Health Systems Management – “the juncture between actuarial science, epidemiology, and population health studies”

54:35 Partnership with HFMA – the marrying of Business with Higher Education to meet future workforce needs.

56:50 A vision for “creating a community of Healthcare Transformationalists”.

62:20 Future leaders in value transformation will need expertise in epidemiology, finance, and clinical operations.

63:50 Grit, passion, and optimism are the most important intangible attributes of future leadership success.

66:35 Parting thoughts from Dr. McEachern and Jenni Gudapati.